<?php

/*
pediatric pain form
This form works as new and editing,
*/
?>
<TABLE span class=text>
<th><H2><U>Pediatric Pain Form</U></H2></th>
<TR>
    <TD >Location:</TD>
    <TD>
        <SELECT NAME="location">
        <option <?php if ($obj["location"]=='ear') {
            print 'selected' ;
}?> >ear
        <option <?php if ($obj["location"]=='troat') {
            print 'selected';
} ?>>troat
        <option <?php if ($obj["location"]=='stomach') {
            print 'selected';
} ?>>stomach
        <option <?php if ($obj["location"]=='head') {
            print 'selected';
} ?>>head
        </SELECT>
    </TD>
    <TD >Duration:</TD>
    <TD>
        <SELECT NAME="duration">
        <option <?php if ($obj["duration"]=='one hour') {
            print 'selected';
} ?>>one hour
        <option <?php if ($obj["duration"]=='twelve hours') {
            print 'selected';
} ?>>twelve hours
        <option <?php if ($obj["duration"]=='one day') {
            print 'selected';
} ?>>one day
        <option <?php if ($obj["duration"]=='two days') {
            print 'selected';
} ?>>two days
        <option <?php if ($obj["duration"]=='three days') {
            print 'selected';
} ?>>three days
        <option <?php if ($obj["duration"]=='more than 3 days') {
            print 'selected';
} ?>>more than 3 days
        </SELECT>
    </TD>
    <TD >Severity:</TD>
    <TD>
        <SELECT NAME="severity">
        <option <?php if ($obj["severity"]=='consolable') {
            print 'selected';
} ?>>consolable
        <option <?php if ($obj["severity"]=='consolable with difficulty') {
            print 'selected';
} ?>>consolable with difficulty
        <option <?php if ($obj["severity"]=='inconsolable') {
            print 'selected';
} ?>>inconsolable
        </SELECT>
    </TD>
</TR>
<TR>
    <TD >Fever:</TD>
    <TD>
        <SELECT NAME="fever">
        <option <?php if ($obj["fever"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["fever"]=='yes') {
            print 'selected';
} ?>>yes
        <option <?php if ($obj["fever"]=='98') {
            print 'selected';
} ?>>98
        <option <?php if ($obj["fever"]=='98,5') {
            print 'selected';
} ?>>98,5
        <option <?php if ($obj["fever"]=='99') {
            print 'selected';
} ?>>99
        <option <?php if ($obj["fever"]=='99,5') {
            print 'selected';
} ?>>99,5
        <option <?php if ($obj["fever"]=='100') {
            print 'selected';
} ?>>100
        <option <?php if ($obj["fever"]=='100,5') {
            print 'selected';
} ?>>100,5
        <option <?php if ($obj["fever"]=='101') {
            print 'selected';
} ?>>101
        <option <?php if ($obj["fever"]=='101,5') {
            print 'selected';
} ?>>101,5
        <option <?php if ($obj["fever"]=='102') {
            print 'selected';
} ?>>102
        <option <?php if ($obj["fever"]=='102,5') {
            print 'selected';
} ?>>102,5
        <option <?php if ($obj["fever"]=='103') {
            print 'selected';
} ?>>103
        <option <?php if ($obj["fever"]=='103,5') {
            print 'selected';
} ?>>103,5
        <option <?php if ($obj["fever"]=='104') {
            print 'selected';
} ?>>104
        <option <?php if ($obj["fever"]=='104,5') {
            print 'selected';
} ?>>104,5
        <option <?php if ($obj["fever"]=='105 ') {
            print 'selected';
} ?>>105
        </SELECT>
    </TD>
    <TD >Lethargy:</TD>
    <TD>
        <SELECT NAME="lethargy">
        <option <?php if ($obj["lethargy"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["lethargy"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
    <TD >Vomiting:</TD>
    <TD>
        <SELECT NAME="vomiting">
        <option <?php if ($obj["vomiting"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["vomiting"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
</TR>
<TR>
    <TD colspan=2 >Able to take oral hydration:</TD>
    <TD>
        <SELECT NAME="oral_hydration_capable">
        <option <?php if ($obj["oral_hydration_capable"]=='yes') {
            print 'selected';
} ?>>yes
        <option <?php if ($obj["oral_hydration_capable"]=='no') {
            print 'selected';
} ?>>no
        </SELECT>
    </TD>
    <TD colspan=2 >Urine output at least every 6 hrs.</TD>
    <TD>
        <SELECT NAME="urine_output_last_6_hours">
        <option <?php if ($obj["urine_output_last_6_hours"]=='yes') {
            print 'selected';
} ?>>yes
        <option <?php if ($obj["urine_output_last_6_hours"]=='no') {
            print 'selected';
} ?>>no
        </SELECT>
        With Pain?:
        <SELECT NAME="pain_with_urination">
        <option <?php if ($obj["pain_with_urination"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["pain_with_urination"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>

    </TD>
</TR>
<TR>
    <TD colspan=2 >Cough or difficulty breathing:</TD>
    <TD>
        <SELECT NAME="cough_or_breathing_difficulty">
        <option <?php if ($obj["cough_or_breathing_difficulty"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["cough_or_breathing_difficulty"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
    <TD colspan=2 >Able to sleep confortably</TD>
    <TD>
        <SELECT NAME="able_to_sleep">
        <option <?php if ($obj["able_to_sleep"]=='yes') {
            print 'selected';
} ?>>yes
        <option <?php if ($obj["able_to_sleep"]=='no') {
            print 'selected';
} ?>>no
        </SELECT>
    </TD>
</TR>
<TR>
    <TD>Nasal Discharge:</TD>
    <TD>
        <SELECT NAME="nasal_discharge">
        <option <?php if ($obj["nasal_discharge"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["nasal_discharge"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
    <TD>Prior Hospitalization</TD>
    <TD>
        <SELECT NAME="previous_hospitalization">
        <option <?php if ($obj["previous_hospitalization"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["previous_hospitalization"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
    <TD>Siblings affected?:</TD>
    <TD>
        <SELECT NAME="siblings_affected">
        <option <?php if ($obj["siblings_affected"]=='no') {
            print 'selected';
} ?>>no
        <option <?php if ($obj["siblings_affected"]=='yes') {
            print 'selected';
} ?>>yes
        </SELECT>
    </TD>
</TR>
<TR>
    <TD colspan=2>Immunization up to date:
        <SELECT NAME="immunization_up_to_date">
        <option <?php if ($obj["immunization_up_to_date"]=='yes') {
            print 'selected';
} ?>>yes
        <option <?php if ($obj["immunization_up_to_date"]=='no') {
            print 'selected';
} ?>>no
        </SELECT>
    </TD>
    <TD colspan=4 align=left valign=top>Notes: 
    <TEXTAREA NAME="notes" ROWS="3" COLS="40">
    <?php if ($obj["notes"]!='') {
        print $obj["notes"];
} ?>
    </TEXTAREA></TD>
</TR>
</TABLE>
